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Drug-resistant "white plague" lurks among rich and poor
By Kate Kelland
<http://blogs.reuters.com/search/journalist.php?edition=us&n=kate.kelland&>,
Health and Science Correspondent
LONDON | Mon Mar 19, 2012 10:25am EDT
LONDON (Reuters)- On New Year's Eve 2004, after months of losing weight
and suffering fevers, night sweats and shortness of breath, student Anna
Watterson was taken into hospital coughing up blood.
It was strange to be diagnosed with tuberculosis (TB)- an ancient
disease associated with poverty - especially since Watterson was a
well-off trainee lawyer living in the affluent British capital of
London. Yet it was also a relief, she says, finally to know what had
been making her ill for so long.
But when Watterson's infection refused to yield to the three-pronged
antibiotic attack doctors prescribed to fight it, her relief turned to
dread.
After six weeks of taking pills that had no effect, Watterson was told
she had multi-drug resistant TB, or MDR-TB, and faced months in an
isolation ward on a regimen of injected drugs that left her nauseous,
bruised and unable to go out in the sun.
"My friends were really shocked," Watterson said. "Most of them had only
heard of TB from reading Victorian novels."
Tuberculosis is often seen in the wealthy West as a disease of bygone
eras - evoking impoverished 18th or 19th century women and children
dying slowly of a disease then commonly known as "consumption" or the
"white plague".
But rapidly rising rates of drug-resistant TB in some of the wealthiest
cities in the world, as well as across Africa and Asia, are again making
history.
London has been dubbed the "tuberculosis capital of Europe", and a
startling recent study documenting new cases of so-called "totally drug
resistant" TB in India suggests the modern-day tale of this disease
could get a lot worse.
"We can't afford this genie to get out of the bag. Because once it has,
I don't know how we'll control TB," said Ruth McNerney, an expert on
tuberculosis at the London School of Hygiene and Tropical Medicine.
INTERNATIONAL ALARM
TB is a bacterial infection that destroys patients' lung tissue, making
them cough and sneeze, and spread germs through the air. Anyone with
active TB can easily infect another 10 to 15 people a year.
In 2010, 8.8 million people had TB, and the Geneva-based World Health
Organization (WHO) has predicted that more than 2 million people will
contract multi-drug resistant TB by 2015. The worldwide TB death rate
currently runs at between two and three people a minute.
Little surprise, then, that the apparently totally untreatable cases in
India have raised international alarm.
The WHO has convened a special meeting on Wednesday to discuss whether
the emergence of TB strains that seem to be resistant to all known
medicines merits a new class definition of "totally drug-resistant TB",
or TDR-TB.
If so, it would add a new level to an evolution over the years from
normal TB, which is curable with six months of antibiotic treatment, to
the emergence of MDR-TB, then extensively drug-resistant TB (XDR-TB).
What's so frustrating about that progression, says Lucica Ditiu of the
WHO's Stop TB Partnership, is that all drug-resistant TB "is a totally
man-made disease".
Like other bacteria, the TB bug Mycobacterium tuberculosis can evolve to
fight its way past antibiotic medicines. The more treatment courses
patients are given and fail to complete, the stronger and more
widespread the resistance becomes.
"The doctors, the healthcare workers, the nurses, entire healthcare
systems have produced MDR-TB. It's not a bug that has come from nature.
It's not a spontaneous mutation. It came about because patients were
treated badly -- either with poor quality drugs, or not enough drugs, or
with insufficient observation so the patient didn't finish the treatment
course," said Ditiu.
Ditiu is somewhat reassured that the WHO is meeting to look at recent
extreme cases of drug-resistance, which will at least throw a spotlight
on this often-forgotten disease. But she says while definitions are
central to international guidelines and treatment protocols, they make
little difference to sick people.
"What is much more important is the drama and tragedy of the human
beings. Whether it's MDR, XDR or TDR TB, it doesn't make much difference
to the patients. A lot of them will face a very, very unfortunate fate."
WHEN THE DRUGS DON'T WORK
The situation in India is a case in point.
Dr Zarir Udwadia, a tuberculosis specialist at the Hinduja National
Hospital in Mumbai, published a paper in the Clinical Infectious
Diseases journal late last year documenting four cases of TDR-TB. He
told Reuters he has now identified 12 cases for which he has all but run
out of treatment options. Three are already dead.
He has tested one powerful anti-TB drug after another on samples
cultured from these patients - including first-line treatments like
isoniazid, rifampicin and streptomycin, and a range of second line drugs
like moxifloxacin, kanamycin and ethionamide. Each medicine failed.
"If you add it all up, they were resistant to 12 drugs in total," he said.
Like others, Udwadia blames poor medical practice.
Non-prescription and over-the-counter antibiotic use is rife in India
and it may be no coincidence that the country now has one of the highest
burdens on MDR-TB in the world, with more than 100,000 cases.
Udwadia's team conducted a recent study in Mumbai, home to more than 12
million people often living in harsh and overcrowded conditions, and
found in one district only five out of 106 doctors in the unregulated
private sector could give a correct prescription for a hypothetical
patient with MDR-TB.
Most of the prescriptions were "inappropriate" and would only have made
the patient worse - driving the conversion of MDR tuberculosis to XDR
and then to TDR tuberculosis.
The Mumbai findings show that totally drug-resistant TB "was an accident
waiting to happen," Udwadia said.
"To get to this stage, you have to have amplified resistance over years,
with loads of misuse of (antibiotic) drugs. And no other country throws
around second-line drugs as freely as India has been doing."
SPREAD
That might suggest countries that use antibiotics more prudently should
be less vulnerable. Experts are not convinced, and history suggests
otherwise.
One of the biggest difficulties in tackling TB is the ease and speed
with which it spreads. When patients cough, sneeze or spit, they propel
thousands of germ-carrying droplets into the air around them. With
people travelling the world in confined spaces, a disease like TB can
easily hitch a ride.
A good example is extensively drug resistant TB, which first hit world
headlines during an outbreak in South Africa in 2006. Barely four years
later in 2010, the WHO said drug-resistant tuberculosis was at "record
levels" worldwide and a total of 58 countries had reported at least one
case of XDR-TB.
Ditiu fears a similar pattern could emerge with TDR-TB.
"It is spreading, it's spreading as we speak right now," she said. "The
situation is extremely worrying."
Anna Watterson, who took 19 months "out of normal life" for her MDR-TB
to be successfully treated but still qualified as a barrister and now
works in London's law courts, can't be sure where she picked up her
infection.
At the time she was living in the northwest borough of Brent, an area of
London with a large immigrant community and pockets of poverty. Like
millions of others in the British capital, she commuted on the Tube
underground train system most days.
Watterson had also travelled to India a couple of years earlier, and
since TB can lie dormant for long periods, it's also possible she may
have contracted it there.
"You can't be isolated from the rest of the world," she said. "We've
become too complacent about TB, thinking that it's gone away. But the
reality is that until it goes away in the developing world, it's not
going away anywhere."
(Editing by Sonya Hepinstall
<http://blogs.reuters.com/search/journalist.php?edition=us&n=sonya.hepinstall&>)